A scan to be sure…

Both doctors and patients like the idea of certainty. We want to be sure that a patient with chest pain isn’t having a heart attack, and that the patient who seems to have a kidney stone doesn’t actually have an aortic aneurysm. We are trained to think ‘worst first’ and to consider uncommon presentations of common diseases. Most of time this serves us well, but sometimes it can lead us down the rabbit’s hole into a world of testing as a surrogate for certainty. We will go to great lengths to prove something is or isn’t happening, but there’s a dirty little secret in medicine; we’re never 100% sure.

Even in our most certain moments, the chest pain patient with a ECG showing STEMI, the abdominal pain patient with CT proven appendicitis there lives uncertainty. Every test and examination we do in medicine has a sensitivity and specificity (though sometimes the s/s is un-studied and unknown). In emergency medicine we live in a world of uncertainty, and it can be difficult to communicate this with our patients.

“Doctor, how do you know it’s not my appendix?” asks the patient who vomited and has abdominal pain, but a completely reassuring examination “Shouldn’t I have a scan to be sure?”.

In some medical systems, driven by fear of litigation, the answer seems to be yes, the patient should be scanned in order to be sure. But, we should be clear, many of these definitive tests offer only the illusion of certainty, along with the reality of risk. For many of the tests we think of as offering certainty (imaging, angiography, etc) the risks of complications and of false positives of any sort are amplified when the test is applied to patients at very low (but not zero) risk of the disease. Some resource limited systems err in the oposite direction, encouraging clinicians to be overly certain of the lack of pathology in low risk patients.

Do we need to go down the rabbit’s hole of testing every-time? Should we simply tell the patient they don’t have the illness, when there is still a tiny bit of uncertainty? Is there a better way to communicate risk to the patient we think that the risk of disease is low? I think there is, and the path to get there is through better communication. When we see patients at low (but not zero) risk for a condition what we need is usually not more, or better tests, rather better communication. In any doctor-patient interaction there are 2 crucial questions that must be answered, the question of the disease entity the doctor is worried about, and the question of the disease entity the patient is worried about. The first is almost always answered, the second is surprisingly often both unknown and unanswered.

I find it useful to ask patients ‘What’s the thing you were most worried about today?” Sometimes it lines up with what I’m worried about and sometimes not, regardless that question is the reason the patient came to the emergency and the patient deserves to have that question answered and explained. Then I say to the patient; ‘When I first hear a story like yours I am worried about X. Today, when we really flesh the story out, and did a good exam I can tell you that I think you are at low risk for X and here’s why…” Then I disclose to the patient medicine’s dirty little secret, we are never 100% sure, and I try to give a risk estimation to the patient. Then I try to gauge the patients personal risk tolerance and reconcile with the actual risk level, sometimes there are tests we should consider in particularly risk averse patients. Finally I give the patient a brief summary of the cues that will bring them back to my care.

In summary:

Answer the concern that prompted the patient to come to the emergency department

Answer the concerns you had when you heard the patients story

Disclose the risk level as accurately as possible to the patient

Try to reconcile the risk level and the patients risk tolerance

Give the patient a brief summary of cues to return to the emergency department

There is always resistance to this approach, doctors believe it will take too much time or that patients won’t like this approach. In fact it probably saves time rather than placating patients with potentially un-needed tests, and it is definitely an approach most patients appreciate.

So the next time a patient with abdominal pain and a normal exam asks you if they shouldn’t have a scan, just to be sure, try taking the couple of minutes to have a discussion about shared risk. I think you will be surprised how effective this strategy actually is.

Comments

Hi Aaron
Love this post. Good consultation skills are central to quality patient care.
Performing a CT etc is not = to good care. In fact it might be doing unnecessary harm
In some cases. The goal is not to exhaust every diagnostic algorithm , but to get to a point where
The patient is satisfied and the doc is happy that the big Qs are answered.
As a GP we often use time and dynamic feedback from the patient to avoid invasive or expensive / irradiating tests. This can be tough to do in an ED, however if you negotiate well and inform the patient – make sure they know when to return then you can do this well
Great stuff
Casey